Archive June 21, 2019

Who You Callin’ Riffraff

The following post was originally a “d’var Torah” (the proper Hebrew term for a sermon) I delivered to my congregation on June 2, 2018.  I’ve added some examples, removed others, and taken out many of the specific citations.  If you’re interested in reading the original, email me at [email protected] and I’d be happy to send you a copy.

Only in Israel.  During the 1999 Israeli elections, actress and singer Tiki Dayan, known prior to that point for several Shakespearean roles and as the narrator in a Hebrew-language production of Joseph and the Amazing Technicolor Dreamcoat, took the stage at an artists’ conference where Labor candidate Ehud Barak was scheduled to speak.  In her speech, Dayan used an epithet straight from the Torah to describe the supporters of Barak’s opponent, the once-and-future Prime Minister Bibi Netanyahu, calling them “asafsuf min ha shuk.”

“Riffraff from the marketplace.”

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Make this Right

A few days ago I upgraded my mobile phone.  I transferred years of accumulated data and apps in nearly seamless fashion and can now unlock the thing with my face.  Yet the most amazing thing I witnessed in the process of purchasing this magical device had nothing to do with technology.

A man in a t-shirt and sunglasses appeared in the doorway of the store where I was making the exchange and called out to the store manager.  “Hey, you got a minute?” he yelled to the tall, bearded guy telling me how much I was overpaying for my service plan.  “I need to make this right.”

The “this” that he needed to make right turned out to be the loose ends of a heated exchange he had with the manager perhaps an hour earlier.  At some point in that conversation the fellow with the shades hurled a couple of expletives and the bearded guy – who responded by tossing him out of the store.

“Take your time,” he said now.  “I just gotta make this right.  I’ll come back when you’re done.”  He was, amazingly, hell-bent on apologizing for his language, and letting the manager know how sorry he was.

He’s my new hero, because I know how hard that was for him. 

If you are a primary care doctor, I advise you to set a life goal of never needing to be in your practice manager’s office with a patient – it is a surrogate marker of a complete communication breakdown.  But a while back, I found myself in my practice manager’s office with a person I’d been taking care of for years. 

Over the course of three days they had been on the phone with half-a-dozen people in my practice, from reception staff to medical assistants to nurses and finally the practice manager, asking for a refill of a medication in a dose that didn’t match anything on their medication list.  In fact, that medication did not even come in the amount they were asking for.  Over and over my co-workers sent me tasks asking for clarification – and over and over I repeated what they already knew to be true: I am absolutely certain of the dose of this medicine, I am not prescribing more than this amount, and I already sent in a prescription for the previous amount.

When my firm stance didn’t change the patient’s mind, they went to the practice manager, who got involved to stop them from screaming at the front office staff.  About to enter a room to see a scheduled patient, I decided to take a detour to the office, thinking I would stride in, put my doctor foot down, show the person the error of their ways and extract an apology to the staff, who were feeling abused and demoralized.

I casually opened the person’s chart, brought up the medication list and pointed triumphantly at the screen.  “See, look right here!  It says….”

I trailed off into silence.  An old prescription for two pills a day of the next to highest dose of the medication, adding up to precisely what the patient had asked for, stared me in the face.  All it said “right here” is that the patient was right all along and I was in such a hurry to get on with my day I hadn’t read the record carefully.  I even had a letter on file from the specialist who had recommended this unconventional dose but was no longer able to prescribe it themselves.

This time I was the one who dropped the unintentional expeletive.  “Oh ****, __________, I’m sorry.  This is my fault.  You were right and I trusted my memory instead of looking more carefully.”  I got the front staff their apology, though – from me.

If you read my work regularly, you know I sit in synagogue every week waiting for that sudden connection between what we’re reading from the Torah and what’s going on in my work life.  Primary care medicine is an endless uphill climb, and if there’s one thing I can grab onto each week then it was worth getting myself to shul that day.  This morning I was struck by one line in particular:

“When a man or woman commits any wrong toward a fellow person, thus breaking faith with God, and that person realizes their guilt, they shall confess the wrong they have done.  They shall make restitution…”

Some context: this portion of the Torah contains difficult material.  It has the very disturbing trial by ordeal of the adulteress, and the somewhat perplexing rules for taking a Nazirite vow.   But for me, the most difficult part of the reading is the line I just quoted – not difficult to understand, but to follow.

Admitting error, and then making restitution for it, is so hard that there are entire sectors of the economy devoted to avoiding it: risk management consultants, malpractice defense attorneys, K Street lobbyists.  Both practicing medical professionals and the industries that supply our tools are equally guilty of trying to deny responsibility and dodge confessing our mistakes.  Google Vioxx, or Dalkon Shield, and see what comes up.  Or ask someone who has endured a missed diagnosis, a medication side effect that was minimized by the prescriber, or even the blackballing, gaslighting, and harassment that sometimes follows the application of the label “difficult patient” to someone who challenges the unthinking routine.  We don’t like having our errors pointed out to us, and we enjoy even less having to fess up to committing them, and least of all having to fix the damage we did – so we do whatever we can to get out of it.

I spent part of my afternoon reading the new book Compassionomics, by Cooper University physicians Stephen Trzeciak and Anthony Mazzarelli.  I had been reading the first few chapters last weekend, patting myself on the back because the research they were reviewing, demonstrating how indispensable compassionate behavior is to the practice of sound medicine, is some of the same research I accessed in writing Healing People, Not Patients, and read like a validation of everything I stand for.

Today’s reading was way more uncomfortable.  Discussing the effects of burnout on medical residents, Trzeciak and Mazzarelli identify a long list of behaviors that lack compassion: not fully answering questions, prescribing medication for agitated patients without going to assess them, or skipping diagnostic tests because they might delay discharge.  I squirmed on my previously comfy couch; I could recall doing all of those things as a resident, sometimes even down to being able to picture the nurse, the specific unit of the hospital and the patient’s face.

Then I turned the page and read the story of Gina, a woman who asked her cardiologist for a sleeping medicine because of anxiety over an upcoming, non-heart-related surgery.  When the cardiologist probed deeper, it turned out that Gina had already asked her PCP, who had waved off the request by telling his staff, “If the surgery is the reason she can’t sleep, tell her to ask the surgeon to prescribe it.”

Forget about recalling something I did in residency that I’m not proud of.  I’ve done the same thing as that burned out PCP three or four times this month.  And I know as I’m doing it that I could make more of an effort.  Reading the book today was like having a mirror held up to my actions, like the Biblical prophet Natan telling King David, “You are that man!”  You, Dr. Weinkle, are that burned-out, uncaring PCP.  Do a better job!

Trzeciak and Mazzarelli are making the point that I’ve made dozens of times: there are behaviors that show, rather than tell a person, “I care about you and about what happens to you.”  Every time we turf one of those behaviors to a colleague, it lessens that message of caring (and according to their review of the research, there is often a dose-response effect – the more times we demonstrate a lack of caring, the worse our effect on their outcomes!).

Admitting error is one of those behaviors.  Admitting an error says, “I did something that hurt you and I don’t want to hurt you.  I feel sorry for causing you pain and now it is my responsibility to fix that pain.”  Like most broken things that become stronger in the repair, I have relationships with people I take care of that are more enduring now because of apologies and restorative gestures than they were before the mistake was made.  And these don’t need to be malpractice level errors, either.  The foul can be as minor as saying I would look something up and not getting around to it – a kind of mistake I am currently drowning in, as a chronic over-promiser.

So I need to stop turfing those requests to fill medications that are “someone else’s problem.”  I need to take the time to hear the problem before prescribing a med, even in the middle of a busy work day or of a sleepless night.  I need to deliver on my promises and not just make them to sound like I care.

I need to make this right.

The Doctor’s Decalogue

One of my favorite journal articles of all time is Goldman, Lee, and Rudd’s seminal “Ten Commandments for Effective Consultations,” published in 1983 in Archives of Internal Medicine.  I love it because the Fifth Commandment is “Thou shalt make specific recommendations,” but also because it proves that even cardiologists count on their fingers – after all, isn’t the number of digits on our two hands the whole reason the entire world runs on a decimal system?

There are lists of ten everywhere, from David Letterman to the Bill of Rights.  My sons are constantly making lists of the top ten best athletes in every sport, and then arguing about them as though there is one “right” answer (“How can you say Paul George is any higher than number 7!?!”).  Even Hamilton and Burr had “Ten Duel Commandments (more on those later).”

Tomorrow night begins the Jewish holiday of Shavuot – the agricultural season of first fruits, and seven weeks plus one day since Passover, but, most importantly in today’s world, also the time of the giving of the Torah.  In other words, it’s Ten Commandments season.  So today I bring you a Ten Commandments of Healing, paraphrasing the original ten in a message for those who bring healing and comfort to body and spirit.  Get your fingers ready:

One: “I am Adonai your God, who led you out of Mitzrayim (the Dire Straits) to be your God.”  Our job, our direction, our North Star, is the goal of bringing people out of distress to a place of wholeness, to being able to shed the sick role and be themselves again.  Insofar as we, the healers who come from many traditions to join the community of those who heal human beings, have a common form of worship, it is to see and honor the divine spark within those we treat. 

Two: “Do not make yourself a sculptured image.”  Healing isn’t about the multi-million dollar clinical campus, or the new MRI machine, or the da Vinci robot in the operating room.  It’s about the person with the illness.  One of my mentors in medical school (can’t recall which one) used to say that modern medicine in America suffers from an Edifice Complex.  It’s only gotten worse in the last twenty years.  Honestly, I do my best healing in someone’s living room, and my mood and productivity is much better when I see the sunshine, something that is impossible to do in my two mostly underground offices or the vast majority of hospitals.

Three: “Do not swear falsely by the Name.”  I have had enough of advertisements for hospitals claiming they do patient-centered care but make everyone schedule their visits through an off-site central scheduler, place barriers between people and their own medical records, cancel visits for patients with limited English when an interpreter can’t make it and the provider “doesn’t like to use the phone,” and dozens of other decidedly non-patient-centered inconveniences and cruelties they inflict.  If you are patient-centered, then be patient-centered, don’t just say it.  If you do something that is not patient-centered, admit it and apologize.

Four: “Remember the Sabbath day and keep it holy.”  “Sabbath” (“Shabbat” in Hebrew) means “cessation.”  Hospitals work 24/7, and yet you know when it is after hours or the weekend.  Translator phones, transporters, ultrasound techs, and care coordination suddenly become very hard to come by.  If you work at the VA, reasonably healthy men with no reason to remain in the hospital will spend the weekend as guests of the federal government because there is no van to take them the five hours back to Clarksburg, WV until Monday (Tuesday, if it’s a holiday weekend).  “Remembering” the Sabbath is easy. 

Keeping it holy?  That’s another task.  One of the causes of healer burnout is the feeling that we can never stop, never turn off who we are, never be “out of the office” completely.  I am feeling guilty just thinking about the fact that I have a vacation coming up where I will be far enough away that I really can’t be available.  Yet without that cessation, we use up all of our emotional reserves.  One Jewish tradition holds that at the beginning of Shabbat we each receive an extra soul, a neshama yeteira, spare breath, that departs us when the Shabbat ends.  The Havdallah service marking the end of Shabbat includes the smelling of spices which is supposed to sustain that spare breath for a little longer, to help us make it through the always-challenging return to the secular week.  Giving ourselves that extra breath is not just healthy – it is a commandment that allows us to provide good healing.  When life is in danger, we are allowed to trepass this commandment in order to save life.  If we do not follow this commandment at other times, our own lives, and those of the people we care for, may be in danger.

Five: “Honor your father and your mother, so that you may long endure on the land.”  In Pirke Avot, the book of the Mishna that showcases the collective wisdom of the Rabbis of Roman Palestine, Rabbi Akiva says (verse 3:14), “Beloved is a human being, for they were created in the image of God.”  He goes on to explain that one way in which we know they are beloved is that a “precious vessel” – the Torah, God’s teaching – was given to them. 

What is our precious teaching?  The knowledge of how to heal, both the science and the caring.  We are blessed to be living in the 21st century, when medicine has begun to separate itself from the days when it was brutal, harmful, and based entirely in superstition and dogma.  At the same time, our precious teaching is in the wisdom and courage of the greats who came before us: Osler, Dame Cicely Saunders, Schweitzer, Hawa Abdi.  Akiva quotes from Proverbs 4:2, “Behold, a good teaching has been given to you, my teaching, do not abandon it.”  Even as we question, challenge, and refine our received wisdom, we should continue to hold the essence of this received tradition of caring close to our hearts.

It’s tempting to think, in each generation, that we know better than those that came before us.  Yet the doctors who first prescribed morphine in the 19th century recognized opioid addiction as a disease that they had caused, and responded with concern and compassion.  Did the ensuing generations who stigmatized and criminalized that addiction, and adopted a “blame the victim” mentality, really know better than their forebears?  Or the generation of doctors who have done millions of unnecessary tonsillectomies, cardiac stents, or sinus surgeries, only to discover that the “less is more” restraint of earlier generations was the right way when the hard evidence finally came out?

Six: “Do not murder.”  One of Burr’s commandments concerns having a doctor on site: “Have him turn around so he can have deniability.”  We don’t participate in duels anymore.  But what about the ways in which we know, if we care to look under the surface, that we endanger lives?  I had a houseguest a couple weeks ago who was not medically trained.  She found a book on my shelf by James Lieber entitled Killer Care: How Medical Error Became America’s Third Largest Cause of Death, and What Can Be Done About It.  She was horrified!  Yet we persist in bad, unsafe habits from not washing our hands to not adequately staffing high-risk areas of hospitals.  We insist on using medications which are ripe for complications and bad interactions long after alternatives exist.  We prescribe “palliative chemotherapy” in the face of evidence that patients with stage 4 cancer enrolling directly in hospice actually live longer (and better) than those getting disease-directed treatment.  If we read the evidence, it’s clear that we can no longer “have deniability,” whether for the opioid crisis, unsafe surgeries, or anything else.  We need to take responsibility for the harm we do, not just the healing.

Seven: “Do not commit adultery.”  Where do our loyalties lie?  With the people we care for?  Ask yourself how many times you’ve “cheated on” one of those people, just a little, with a pharmaceutical company who got you to prescribe a different drug?  Or with a research project that turned a person into a subject, suffering into a statistic?  Or with the protocols set for you by a hospital system, an insurer, or someone else who did a wallet biopsy and found your patient (or your treatment plan) to have unfavorable financial markers?

Eight: “Do not steal.”  People’s time, keeping them waiting, bringing them back for “routine” visits and treatments that don’t add life or wellness.  People’s money, prescribing a $50 dollar drug when a $4 one will do.  People’s hopes, either by building up pie-in-the-sky expectations and not being honest about the bad stuff, or by dismissing someone out of hand as hopeless instead of listening and trying.

Nine: “Do not bear false witness against your neighbor.”  We have a bad habit of gaslighting our patients: labeling them drug-seekers, somatizers, malingerers.  Or labeling their diseases with wastebasket diagnoses, telling them there’s nothing wrong with them.  While it’s important not to violate Commandment Eight by overpromising cures and clear diagnoses, it is equally important for them to feel heard and believed when they say it hurts – and not to bias other providers about them to the point where they don’t listen.

Ten: “Do not covet . . . . anything that is your neighbors.”  We have a sacred gift, being entrusted to heal.  Keep that front and center.  Ignore the shiny objects, the lifestyles that are supposedly better or cushier.  This is where you belong – be grateful for the opportunity.

What are your Ten Commandments for healing?

Copyright © 2022 Jonathan Weinkle. All rights reserved.